Anxiety
(_)Actual (_) Potential
| (_)
Anesthesia (_) Anticipated/actual pain (_) Disease (_) Invasive/noninvasive procedure:_________ _____________________________________ (_) Loss of significant other (_) Threat to self-concept (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major:
(Must be present) |
[Physiological] (_) Elevated BP, P, R (_) Insomnia (_) Restlessnes (_) Dry mouth (_) Dilated pupils (_) Frequent urination (_) Diarrhea [Emotional] (_) Patient complains of apprehension, nervousness, tension [Cognitive] (_) Inability to concentrate (_) Orientation to past (_) Blocking of thoughts, hyperattentiveness |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Demonstrate a decrease in anxiety A.E.B.:
(_) Discuss/demonstrate effective coping mechanisms for dealing with anxiety. (_) Other:
|
(_)
Assist patient to reduce present level of anxiety by:
(_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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